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20456 WELL/PUMP PERMIT f -1 - <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205.6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUFn <br />IJOB ADDRESS 'ZD -Q 0 S T Tr n nrn CITY0P . STOCKTON CA 9 5 2 n 6 <br />CROSS STREET W APN— � —no2 PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME PHONE _ 47_Q-4669 <br />OWNER ADDRESS C A M1 <br />CITY/STATE/ZIP <br />CONTRACTOR —Delta Pumv -'Tfl(`Kmr)Ni ARMkz RF & M zQ W -R-y <br />S �'�. 209-466-9fi9 <br />CONTRACTOR ADDRESS 646 S. California Street CITY/STATElZIP Stockton, CA 95203 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 0 C-57 X C-61 0 D-09 _ 0 Other NUMBER <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />INTENDED USE V Jomestic/Private 0 i <br />PHONE <br />CITY/STATE/ZIP <br />EXPIRATIOIi DATE_ ()8/_q <br />Township Range Section <br />C Public Water System rngahon/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterizatlon <br />If different from Owner a er ys am ame <br />c ame or one um er <br />TYPE OF WORK 0 New Well 0 Replacement Well <br />0 Well Alteration/Modification <br />0 Other <br />AlVER Received <br />G Monitoring Wells) # of wefts <br />0 Out -Of -Service Well <br />Q So((Borfng(s) <br />OOut-Of-Service <br /># of borinps <br />0 Geotec <br />Constructed Well Depth ft <br />0 New Pueacement <br />Well Renewal <br />OCross-Connection Repair <br />�p1 <br />NELL CONRUCTION <br />m Re air <br />D R aise Well Casing <br />/ IA. <br />t- <br />Drilling Method C1 Mud Rotary 0 Air Rotary D Auger 0 Cable Tool 0 Push Point 0 Other `S'9N y r i• / <br />Proposed Well Depth ft Excavation in diameter ❑Open Bottom D Gravel Pack/Gravel ate, /R N <br />0 Conductor Casing in diameter / Conductor Casing Depth ft "" JSq- . N ter <br />Well Casing Diameter in Thick nesslGau e/ASTM Sched �F, 9/? <br />g 0 Steel ❑ Plastic 0 Stainless Steel 0 Other MEV <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag15-10 gal water <br />❑Sand Cement sack mixR gal water <br />0 Bentonite (20% solids) ❑Other <br />Grout Placement Method ❑ Pumped D Free Fall ❑ Other <br />_ ❑ Retardant /Accelerator (name) <br />Installed By 0 Driller 0 Pump Contractor 0 Other <br />C Concrete Pedestal Dimensions: Width ft Length ft Thick <br />in ❑Christy Box 0 Stove <br />r'limr X2X5ubmersibleO Turbine O Other HP <br />Pump Set -__4 2__.__ ft Standing Water Level. 14 R <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNT f ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LA� <br />MINI <br />SIGNED Z Z -- <br />24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />?e 7, -1 TITLE CEO DATE 6 11 1 i n R <br />i <br />NOTE: THIS WAS AN EMERGENCY ISSUE OF NO WATER <br />TO THE HOME. WE HAD TO PULL THE PUMP PRIOR TO YOU <br />RECEIVING THIS APPLICATION <br />Louise Fornos <br />Office Manaeer - <br />DE ARTMENT U § E QNLY <br />Application Accepted By Date <br />Are*S�PlFqCIAIL Well Permit Employee ID941� <br />Grout Inspection By ? Date <br />Pump inspection By �. Date <br />In 1A( <br />Soil Boring Inspection By <br />AlVER Received <br />COMMENTS <br />Date <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info B <br />pec <br />Cash <br />Amount <br />Date <br />Permit/ <br />22 // <br />Remitted <br />Service R%el�uest ## invoice # Well ID# <br />I <br />, 1 <br />EHD 43.06 <br />8/04/08 <br />WELL /PUMP PERMIT <br />IM <br />M <br />g <br />M <br />a <br />